Administering tranexamic acid (TA) appears to be safe in reducing the reoperation rate for bleeding after bariatric surgery, according to researchers from Maasstad Hospital, The Netherlands. They reported that TA was not associated with an increase in thromboembolic events, although they acknowledge that larger studies are necessary to confirm the safety and efficacy of this treatment approach.

The researchers outline in their paper, ‘Tranexamic acid therapy for postoperative bleeding after bariatric surgery’, published in BMC Obesity, that TA is a synthetic derivative of the amino acid lysine, a potent antifibrinolytic drug. It prevents the binding of plasminogen to the surface of fibrin and reduces the activation of fibrin, resulting in inhibition of fibrinolysis. The aim of their study was to evaluate their re-operation rate and thrombo-embolic complication rate with the use of tranexamic acid administration in cases of post-operative haemorrhage after bariatric surgery in comparison to those in existing literature.

Bariatric procedures in their centre are laparoscopic gastric bypass and laparoscopic gastric sleeve. The same stapler was used in all cases and no reinforcement was used. Wash is not used during bariatric procedures. During all procedures the surgeon routinely places an abdominal drain. The drain is usually removed one day postoperatively.

The researchers reviewed patients with (suspected) significant post-operative bleeding complications. Forty six patients receiving TA after bariatric surgery or patients re-operated due to postoperative haemorrhage after bariatric surgery were included in the study. Patients receiving tranexamic acid as regular medication were excluded (n=1).

Postoperative haemorrhage was suspected in patients with one or more the following signs: postoperative tachycardia (> 100 bpm), hypotension (systolic pressure < 100 mmHg), an increased drain production (> 100 ml/24 h) or a drop in haemoglobin level of more than 2 mmol/l.

Outcome measures were reoperation rate, transfusion rate and thrombo-embolic events with a follow-up of six months. Patients are seen for clinical follow-up every three months during the first year following bariatric surgery.

Patients who received tranexamic acid were treated with a dosage of 1000mg in 100cc of NaCl intravenously four times daily. This was given until the patient was deemed stable. Blood transfusion was given according to the Dutch Blood Transfusion Guidelines.

Outcomes

In total, tranexamic acid was administered to 44 of the 45 patients who suffered significant postoperative bleeding. The incidence of reoperation due to haemorrhage was 0.4% and two patients were re-operated the same day as the primary surgery because of rapidly increasing hemodynamic-instability. One of these patients did not receive tranexamic acid because they were re-operated immediately. The other three patients were reroperated on day one (n=2) and day two (n=1). This results in a failure of the tranexamic acid treatment in four patients (9%). The origin of haemorrhage during re-operation was found to be the staple-line (n=2), trocar opening (n=1) and of diffuse origin (n=2). There were no mortalities.

The overall transfusion rate was 1.4% (19 of 1,388 patients). In the study population, 19 of the 45 patients received transfusions (42.2%). Four of the five patients re-operated received transfusions. Patients received one to four packed cells.

The median amount of five doses of tranexamic acid was administered (range 0–17). All patients received heparin postoperatively. However, in 29 (64.4%) patients LMWH was continued despite of the occurrence of a haemorrhage. These patients did not require more tranexamic acid than those in which the heparin had been stopped (p=0.52). In 30 cases (66.7%), tranexamic acid was administered on day one postoperative (median day 1.2, range 0–3). At this moment, the patient experienced signs of hypovolemia such as tachycardia, an increased drain production, and a decrease in haemoglobin level.

They reported that there were no thromboembolic complications (such as deep venous thrombosis or lung embolism) in these patients at six months follow-up and no instances of acute kidney injury in the patients receiving TA.

The researchers noted that there are concerns regarding the risk of thromboembolic events, especially in high-risk patient for post-operative thromboembolic events with higher systemic concentrations and prolonged intravenous application and this his may well be the reason why TA after bariatric surgery has not become a popular haemostatic tool.

“Important parameters to take into account when evaluating the patient are: heart rates, blood pressure, drain production, and haemoglobin levels,” they write. “Patients who are hemodynamically unstable should undergo a diagnostic laparoscopic reoperation. However, in the patients with suspected haemorrhage who are not in shock, this conservative approach with the use of tranexamic acid could be a treatment option.”